Mycotic pseudoaneurysms develop at sites of intimal disruption where bacterial invasion occurs. The conventional treatment involves arterial ligation, excision and debridement, followed by a bypass procedure at a later point. Recently, covered stent grafts have been used to treat mycotic arterial aneurysms either as temporary or definitive procedures. However, this is associated with a risk of stent graft infection, recurrence and rupture. There is a paucity of long-term results on the durability of such endovascular stent graft procedures in mycotic arterial pseudoaneurysms. We describe a successful endovascular covered stent repair of a mycotic profunda femoris artery pseudoaneurysm and follow-up of this repair at 2 years.

Preoperative axillary ultrasound (USS) and fine needle aspiration cytology (FNAC) may allow diagnosis of axillary metastases and reduce repeat axillary procedures. This procedure is usually performed by radiologists. The aim of this prospective study was to evaluate the diagnostic accuracy of surgeon performed axillary USS and/or FNAC in determining axillary nodal status preoperatively. Patients with invasive breast cancer from August 2007 to July 2008 were studied prospectively. Patients who had primary hormonal therapy, neo-adjuvant therapy or distant metastases were excluded. Axillary USS was performed by two consultant breast surgeons trained in ultrasound and biopsy techniques. USS guided FNAC was used to evaluate suspicious nodes. Those with positive cytology (i.e., malignant cells) underwent axillary clearance and the remainder had either sentinel lymph node biopsy or axillary node sample. Axillary USS and FNAC results were compared with final axillary histology. One hundred and twenty eight patients were included with a mean age of 60 years. Nodes were nonpalpable in 96(75%) patients. Forty nine(38.2%) patients had axillary metastases on final histology and 30 of the 49(61%) were identified by preoperative USS guided FNAC. The sensitivity and specificity of this procedure were 61% and 100%, respectively. The positive predictive value and negative predictive value were 100% and 80.6%, respectively. Therefore, 61% of patients with axillary metastases were able to proceed directly to definitive axillary surgery. The use of USS and FNAC to evaluate and sample the axillary nodes in patients with invasive breast cancer can be a useful tool for the breast surgeon.

Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins (Br J Surg 2008; 95: 294-301) SirWith the increasing awareness in public of the role of minimally invasive techniques, it is exciting to read about evidence from a randomized controlled trial of the use of endovenous laser ablation as an option for the treatment of varicose veins. Interestingly, the population of patients entered into the trial were highly selected and do not represent patients offered surgery within the NHS. It is the highly tortuous GSV and large incompetent anterior thigh veins that can pose the greatest challenge to the surgeon.Moreover, the treatment modalities offered in each arm were so vastly different that it would be difficult to attribute benefit to the laser therapy in the treatment arms of the trial. There appeared to be a very small numbers recruited, with 398 patients excluded, 221 not meeting the inclusion criteria and 177 declining treatment. Of the 276 recruited, only 136 were eventually randomized, forcing the conclusion that the P values are in effect invalid. The fallout to follow-up also is of concern adding to bias, and unfortunately the authors do not elucidate the cause or the reasons for creating such an exclusion criterion. Finally, is abolition of GSV reflux not a surrogate marker for treatment? Does GSV reflux correlate well with symptomatic varicose veins?Authors' reply: Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins (Br J Surg 2008; 95: 294-301)

Testicular germ cell tumours are the most common malignancies in men aged 15-40 years.1 There has been an increased incidence over the past few decades in the UK, 2,3 US 4 and other Caucasian populations. 5 Although the aetiology is unknown, developmental urogenital abnormalities, 6 undescended testes and inguinal hernias have all been associated with higher rates, 7 with sedentary lifestyle, early puberty and genetics also implicated as risk factors. 8-10The British Testicular Tumour Panel and Registry classifies malignant testicular germ cell tumours into two main histological groups: seminomas and teratomas. 11Para-aortic lymph nodes are the most common sites of metastatic disease.Along with the tumour pathology and clinical stage, preoperative staging investigations inform the choice of further treatment, which may be surveillance, chemotherapy or radiotherapy.12 Chemotherapy is usually recommended for those with evidence of metastatic disease while surgical resection is considered for patients with significant residual masses, particularly in the para-aortic region.Surgery is most likely to play a role in improving the outcome of treatment by resecting residual masses in intermediate and poor prognosis patients who are in remission following chemotherapy.Retroperitoneal lymph node dissection (RPLND) is the most common form of surgery required 13 and national guidance recommends that the treatment of patients with advanced disease or recurrence should be carried out in specialised centres.14 In the North Trent Cancer Network (NTCN), vascular surgeons have been members of the germ cell multidisciplinary team and patients requiring RPLND for metastatic testicular cancer have been treated by the vascular service since 1990. This paper reviews our experience and considers the case for involvement of vascular surgeons in the management of these tumours. MethodsAll patients diagnosed with testicular germ cell tumour in the NTCN between 1990 and 2009 were entered into a germ cell database. Patients referred to the vascular service for RPLND were identified through this database. The main indications for surgical referral were a residual para-aortic mass of >1-2cm after chemotherapy or as part of the treat- ABSTRACT inTRodUCTion in the north Trent Cancer network (nTCn) patients requiring retroperitoneal lymphadenectomy for metastatic testicular cancer have been treated by vascular service since 1990. This paper reviews our experience and considers the case for involvement of vascular surgeons in the management of these tumours. PaTiEnTS and mEThodS Patients referred by the nTCn to the vascular service for retroperitoneal lymphadenectomy between 1990 and 2009 were identified through a germ cell database. data were supplemented by a review of case notes to record histology, intraoperative and postoperative details. RESULTS a total of 64 patients were referred to the vascular service for retroperitoneal lymph node dissection, with a median age of 29 years (16-63 years) and a median follow-up of 4.9 years. Ten patients ...

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